16 December 2004

NSW Government response to Sentinel Events Review Committee report

Minister for Health, Morris Iemma said today that the Government had completed its response to the first report of the NSW Mental Health Sentinel Events Review Committee.

The Committee was established in May 2002 by the NSW Government to independently review and report on morbidity and mortality issues related to the care of people with mental illness.

The first report of the Committee, Tracking Tragedy: A systemic look at the suicides and homicides amongst mental health inpatients was released in December 2003.

Led by Professor Peter Baume, the Committee made 52 recommendations relating to:

• Risk assessment and management of patients;
• Staffing of inpatient facilities;
• Clinical practice and care;
• Involvement of families;
• Communication,
• Documentation of illnesses and treatments;
• Training;
• Data collection; and
• Coronial processes.

Mr Iemma said that most of the recommendations of the Committee were supported by the Government and were either in the process of being implemented or would shortly be implemented.

“The Committee report found that in general mental health services in NSW are doing a very effective job at managing people with severe mental illnesses,” Mr Iemma said.

“It noted that suicide deaths by mental health inpatients are rare events compared to the numbers receiving specialised care, and homicides were even rarer still.

“But while the assessment of people at risk of suicide is inherently complex wherever they come into contact with the health system, we must always try to do better.

“Getting on with the job of implementing these recommendations will contribute to further improving the care and safety of inpatients in NSW mental health services.”

A full copy of the NSW Government response to Tracking Tragedy is available at www.health.nsw.gov.au.

Guided by the recommendations of the Committee and the earlier report of the Legislative Council’s Select Committee Inquiry into Mental Health Services, Mr Iemma said a number of steps to improve mental health services in NSW had already been taken. These included:

• The addition of $241 million to enhance mental health services between 2004/05 to 2007/08, and a further $76 million over the next four years to support the mental health capital works program;

• The addition of 115 mental health beds in the past two years under the accelerated beds program with a further 290 beds approved and in the process of being planned or built through to June 2008;

• The trial of Psychiatric Emergency Care centres at Nepean and Liverpool Hospitals, providing specialist assessment and care to mental health patients in Emergency Departments;

• The commencement of a review of the Mental Health Act 1990, which to date has sought and received public comment on two discussion papers relating to all aspects of patient care;

• The development of a new suicide prevention policy document for all staff working with people with a mental illness, the Framework for Suicide Risk Assessment and Management. The policy has been distributed to all Area Health Services and will be supported by a statewide training program;

• The allocation of additional funds for the Nursing ReConnect program to attract more nurses back into the system to work in the area of mental health; and

• The establishment of a pilot project within the Mid North Coast Area Health Service for the transport and treatment of acutely mentally ill patients, the Rural Mental Health Critical Care Project.

Background to the Sentinel Events Review Committee report Tracking Tragedy

• The Sentinel Events Review Committee looked at a sample of 35 inpatient suicides over a five year period and eight homicides perpetrated by patients of mental health services between 1999 and 2002, in order to analyse systemic factors that may have contributed to these events.

• In 2002/03 there were 22,061 admissions to public mental health units and eight inpatient suicide deaths.

• In the three years to 2003, there were almost 62,000 admissions to public mental health units and 20 homicides perpetrated by patients in contact with mental health services.

For a range of health information, go online to www.health.nsw.gov.au